BROADENING THE SCOPE OF THE EASTERN SYDNEY AREA SENTINEL SURVEILLANCE ... · The general...
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BROADENING THE SCOPE OF THE EASTERN SYDNEY AREA SENTINEL SURVEILLANCE NETWORK Leena Gupta and Mark Ferson Eastern Sydney Public Health Unit T he general practice-based sentinel surveillance network in Eastern Sydney Area (ESA) has been operating for two years. Its purpose has been to document temporal variations in general practice consultation rates for specific diseases, to detect epidemics or disease clusters and to contribute to Statewide influenza surveillance. Until October 1993 conditions reported by participating general practitioners (GPs) included influenza, asthma, chickenpox, hand, foot and mouth disease and shingles. Aggregate data are reported in a monthly bulletin produced by the ESA Public Health Unit. In October 1993 we conducted a review of general practice- based sentinel surveillance in ESA. We interviewed participating GPs and contacted other units in NSW which coordinate general practice-based sentinel surveillance. The 13 GPs interviewed reported they found participation in the network useful to their clinical practice, particularly in the provision of aggregate information to patients. Several GPs considered it unnecessary to report some infectious conditions and suggested alternatives, such as domestic violence, injuries, acne in adolescence, pap smears and requests to screen for sexually transmitted diseases. In contacting other units which co-ordinate sentinel surveillance, we found that some units had broadened the scope of reporting to include such conditions as occupational injury, alcohol-related consultations and marital disharmony. As a result of the review we modified the list of conditions reported and have now included only those in which clinical, public health or other (social, economic) intervention maybe implemented in ESA, or where the impact of intervention could be monitored. Specifically, we have reduced the extent to which infectious diseases are reported and begun reporting of known or suspected cases of domestic violence. In ESA sentinel surveillance age/sex data on domestic violence have been collected for 10 months using a case definition developed with the ESA Women's Health Coordinator. GPs also classiiv the manifestations of domestic violence as physical, psychological, sexual, social/cultural or economic. The data on domestic violence have considerable public health significance, in view of a previous study in an Eastern Sydney emergency department, where domestic violence accounted for 12 per cent of 512 presentations for injuries due to violence in a six-month period'. Studies elsewhere have demonstrated that between 1 per cent and 20 per cent of women who present to a hospital emergency department have a recent history of domestic violence'. The collection of this information is relevant to the development and implementation of the NSW Domestic Violence Strategic Plan5, the NSW Health Department Domestic Violence Policy6 and the ESA Health Service Domestic Violence Policy and Protocol6, all of which identified the need for further data collection. Care has been exercised in interpreting data obtained because of methodological difficulties inherent to voluntary small-scale sentinel surveillance systems. Bias is of particular concern because the surveillance network is not population-based - the participating GFs are volunteers and are not distributed evenly by geographic location, practice demographics or casemix. In addition, compliance is variable. As a result, data are not representative of the population seen by GPs in ESA. Poor sensitivity is also a significant limitation, as case definitions for domestic violence and its manifestations have been simplified to assist in rapid assessment and classification of patients for reporting purposes. This has resulted in underreporting of cases and may result in misclassification. Despite these limitations we believe reporting of domestic violence has been valuable because of the paucity of data about the problem. From data collected by the surveillance network it will, at least, be possible to determine baseline consultation rates for participating practitioners and to detect temporal trends in consultation rates over longer periods, as further strategies to increase recognition and improve management of domestic violence are implemented. The value of the data may also be in estimating the proportion of domestic violence presentations to GPs with a certain manifestation - for example, the proportion of consultations for domestic violence in which social/cultural abuse is a manifestation. Most important, the collection of primary care data on domestic violence will complement data from, for example, emergency presentations and will be an indicator of the need for more extensive data collection. Since ESA PHU began data collection on domestic violence, some other sentinel networks have started collecting similar data. We have also considered monitoring other conditions, to complement current clinical or preventative initiatives. These "conditions" include injuries due to falls (the leading cause of hospitalisation for injury in 1989-1990), presentations with scalds and refeuals for mammography. The possibility of reporting self-inflicted injuries provides a mechanism by which the general practice-based sentinel surveillance network could link with the ESA Health Outcomes Council which is focusing on suicide. Amendments to the existing list of conditions will be made in consultation with participating GPs. Previous articles in the NSW Public Health Bulletin have indicated potential benefits of general practice-based surveillance networks5-'°. Mira et al'° have suggested that sentinel surveillance has the potential to monitor conditions other than infectious diseases and preventative care. We consider that the scope of "conditions" reported by general practice-based sentinel surveillance networks can be broadened farther to provide a useful mechanism for monitoring the impact of a wide range of public health and health promotion initiatives, social welfare programs or clinical services, at a local or statewide level. ACKNOWLEDGMENT We gratefully acknowledge Susan Furber, David Lyle, Karen Alexander and Michael Mira for their input and thank all the general practitioners who have participated in the network. 1. Fulde GWO, Cuthbert M, Kelly R. Violence in society: fact or fiction? Emergency Mcd 1991; 3 :37(80):5 154. 2. Roberts GL, OTco1e fit, Lawrence JM et al. Domestic violence victims in a hospital emergency department. Med JA05t 1993; 159:307-310, VoI.5/No.11121
Transcript of BROADENING THE SCOPE OF THE EASTERN SYDNEY AREA SENTINEL SURVEILLANCE ... · The general...
BROADENING THE SCOPE OF THE EASTERN SYDNEY AREASENTINEL SURVEILLANCE NETWORK
Leena Gupta and Mark FersonEastern Sydney Public Health Unit
The general practice-based sentinel surveillance networkin Eastern Sydney Area (ESA) has been operating for
two years. Its purpose has been to document temporalvariations in general practice consultation rates for specificdiseases, to detect epidemics or disease clusters and tocontribute to Statewide influenza surveillance. UntilOctober 1993 conditions reported by participating generalpractitioners (GPs) included influenza, asthma, chickenpox,hand, foot and mouth disease and shingles. Aggregate dataare reported in a monthly bulletin produced by the ESAPublic Health Unit.
In October 1993 we conducted a review of general practice-based sentinel surveillance in ESA. We interviewedparticipating GPs and contacted other units in NSW whichcoordinate general practice-based sentinel surveillance. The13 GPs interviewed reported they found participation in thenetwork useful to their clinical practice, particularly in theprovision of aggregate information to patients. Several GPsconsidered it unnecessary to report some infectiousconditions and suggested alternatives, such as domesticviolence, injuries, acne in adolescence, pap smears andrequests to screen for sexually transmitted diseases. Incontacting other units which co-ordinate sentinelsurveillance, we found that some units had broadened thescope of reporting to include such conditions as occupationalinjury, alcohol-related consultations and maritaldisharmony.
As a result of the review we modified the list of conditionsreported and have now included only those in which clinical,public health or other (social, economic) intervention maybeimplemented in ESA, or where the impact of interventioncould be monitored. Specifically, we have reduced the extentto which infectious diseases are reported and begunreporting of known or suspected cases of domestic violence.In ESA sentinel surveillance age/sex data on domesticviolence have been collected for 10 months using a casedefinition developed with the ESA Women's HealthCoordinator. GPs also classiiv the manifestations ofdomestic violence as physical, psychological, sexual,social/cultural or economic.
The data on domestic violence have considerable publichealth significance, in view of a previous study in anEastern Sydney emergency department, where domesticviolence accounted for 12 per cent of 512 presentations forinjuries due to violence in a six-month period'. Studieselsewhere have demonstrated that between 1 per cent and20 per cent of women who present to a hospital emergencydepartment have a recent history of domestic violence'.The collection of this information is relevant to thedevelopment and implementation of the NSW DomesticViolence Strategic Plan5, the NSW Health DepartmentDomestic Violence Policy6 and the ESA Health ServiceDomestic Violence Policy and Protocol6, all of whichidentified the need for further data collection.
Care has been exercised in interpreting data obtainedbecause of methodological difficulties inherent to voluntarysmall-scale sentinel surveillance systems. Bias is ofparticular concern because the surveillance network is notpopulation-based - the participating GFs are volunteers andare not distributed evenly by geographic location, practice
demographics or casemix. In addition, compliance isvariable. As a result, data are not representative of thepopulation seen by GPs in ESA. Poor sensitivity is alsoa significant limitation, as case definitions for domesticviolence and its manifestations have been simplified toassist in rapid assessment and classification of patients forreporting purposes. This has resulted in underreporting ofcases and may result in misclassification.
Despite these limitations we believe reporting of domesticviolence has been valuable because of the paucity of dataabout the problem. From data collected by the surveillancenetwork it will, at least, be possible to determine baselineconsultation rates for participating practitioners and todetect temporal trends in consultation rates over longerperiods, as further strategies to increase recognition andimprove management of domestic violence areimplemented. The value of the data may also be inestimating the proportion of domestic violence presentationsto GPs with a certain manifestation - for example, theproportion of consultations for domestic violence in whichsocial/cultural abuse is a manifestation. Most important,the collection of primary care data on domestic violencewill complement data from, for example, emergencypresentations and will be an indicator of the need formore extensive data collection.
Since ESA PHU began data collection on domestic violence,some other sentinel networks have started collecting similardata. We have also considered monitoring other conditions,to complement current clinical or preventative initiatives.These "conditions" include injuries due to falls (the leadingcause of hospitalisation for injury in 1989-1990),presentations with scalds and refeuals for mammography.The possibility of reporting self-inflicted injuries providesa mechanism by which the general practice-based sentinelsurveillance network could link with the ESA HealthOutcomes Council which is focusing on suicide. Amendmentsto the existing list of conditions will be made in consultationwith participating GPs.
Previous articles in the NSW Public Health Bulletin haveindicated potential benefits of general practice-basedsurveillance networks5-'°. Mira et al'° have suggested thatsentinel surveillance has the potential to monitor conditionsother than infectious diseases and preventative care. Weconsider that the scope of "conditions" reported by generalpractice-based sentinel surveillance networks can bebroadened farther to provide a useful mechanism formonitoring the impact of a wide range of public healthand health promotion initiatives, social welfare programsor clinical services, at a local or statewide level.
ACKNOWLEDGMENTWe gratefully acknowledge Susan Furber, David Lyle,Karen Alexander and Michael Mira for their input andthank all the general practitioners who have participatedin the network.
1. Fulde GWO, Cuthbert M, Kelly R. Violence in society: fact or fiction?Emergency Mcd 1991; 3 :37(80):5 154.2. Roberts GL, OTco1e fit, Lawrence JM et al. Domestic violence victimsin a hospital emergency department. Med JA05t 1993; 159:307-310,
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Tobacco
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displayed more than one advertising sign that breachedthe Act.
DISCUSSIONOverall, 90.5 per cent of tobacco retailers in suburbanshopping centres and 96.2 per cent of service stationscomplied with the Act at the initial survey. This may havebeen due to a number of factors. In mid-1993, the NSWHealth Department wrote to all tobacco retailers explainingthe legislation. In addition, before the September 30deadline, tobacco companies began supplying legaladvertising material to retailers. Some advice andadvertising material from the tobacco companies, however,does not comply with the Act.
The most common advertising breaches were those thatadvertised the availability of tobacco products, e.g."Cigarettes sold here". In many instances these signs wereprovided by the tobacco companies and were in the coloursof major tobacco companies. Tobacco retailers were happy toremove these illegal advertising signs, especially when theywere told they were liable to prosecution rather than thetobacco companies.
All but one tobacco retailer had complied by the finalinspection. This retailer is a member of a majorsupermarket chain. We were told by the management thatits advertising policy was determined at the corporate leveland that it would eventually comply. We did not prosecutethe retailer as the NSW Health Department is negotiatingwith the supermarket chain.
Warning letters seemed to alter advertising behaviour insome of the retailers. We did not have sumcient statisticalpower to evaluate the effectiveness of warning letters inchanging advertising behaviour. In view of limitedresources, it is important, in a future study, to compare therelative effectiveness of warning letters and visits by anEHO in changing advertising behaviour. It should be noted
Sentinel surveillance network
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3. McLeer VA, Anwar R. A study of battered women presenting in anemergency department. Am JPublic Health 1989; 79(1)65-66.4. Goldberg WG Tomlanovich MC. Domestic violence victims in anemergency department. JAMA 1984; 251:3259-3264.5. NSW Domestic Violence Committee. Report of the NSW DomesticViolence Committee. NSW Domestic Violence Strategic Plan. NSWWomen's Coordination Unit, July 1991.6. NSW Health Department. Domestic Violence Policy. March 1993.7. Eastern Sydney Area Health Service. Draft Domestic Violence Policyand Protocol, January 1994.8. Brown JA, Towler BP, Stokes ML, Injury Profile. An overview of injuryin Eastern Sydney. 1993. Public Health Unit, Eastern Sydney AreaHealth Service.9. Jeffs D, McMabon R. Sentinel General Practices. NSW Public HealthBulletin 1990; 12(11:51-52.10. Mira M. Cooper C, Britt H. Benefits of general practice sentinelsurveillance networks. NSW Public Health But Irfin 1992; 3(11): 121-122.
that very high compliance rates were achieved in the surveypopulation without recourse to prosecutions.
Specialist tobacconists had the highest failure rate. It maybe that as the retailing of tobacco products is their solesource of livelihood they are willing to risk illegaladvertising. In any education campaign, they should begiven a high priority.
We did not record any breaches in business names. At thetime of the study, there was debate about whether it waslegal to use the word "tobacconist" in registered businessnames. If business names such as "discount tobacconist"were not permissible, there would have been 25 additionalbreaches and 16 additional offending retail outlets. It is nowNSW Health Department policy, however, that businesssigns with the word "tobacconist" are acceptable providedthey are part of a registered business name and comply withthe spirit of the Act.
The survey method was labour-intensive. A list of licensedtobacco retail outlets was unavailable. Such a list wouldhave ensured a complete sampling frame.
In summary, it was gratifying that most tobacco retailers inshopping centres and service stations in western Sydneywere complying with the Tobacco Advertising ProhibitionAct 1991. Specialist tobacconists, however, have a high non-compliance rate. This group of retailers will need to betargeted in any follow-up publicity or education campaigns.
ACKNOWLEDGMENTSWe would like to thank the Drug and Alcohol Directorate,NSW Health Department, for funding this study.
1. US Department of Health and Services. The Health Benefits ofSmoking Cessation. A Report of the Surgeon General 1990.2. d'Espaignet ET, van Onimeren M, Taylor F, Briscoe N, Pentony P.Trends in Australian Mortality 1921-1988. Australian Institute ofHealth. Australian Government Publishing Service, Canberra 1990.3. Jalaludin B, Smith W, Salkeld G, Chey T, Capon A. PopulationAttributable Risks in Setting Priorities for Interventions in CancerPrevention. Western Sector Public Health Unit 1993.4. Dobson E, Woodward S, Leeder S. Tobacco smoking in response tocigarette advertising. (Letter) Med JAust 1992; 156(111:815-16.5. Pierce JP, Gilpin E, Bums DM et al. Does tobacco advertising targetyoung people to start smoking? Evidence from California. JAM4 1991;266(22);3185-86.
PUBLIC HEALTH EDITORIAL STAFFThe editor of the Public Health Bulletin is Dr Michael Frommer,Director, Research and Development, NSW Health Department;production manager is Dr Marie-Louise Stokes, and assistant editoris Dr Valerie Delpech.
The Bulletin aims to pmvide its readers with population health dateand information to motivate effective public health action. Articles,news and comments should be 1,000 words or less in length andinclude a summary of the key points to be made in the firstparagraph.
Please submit items in hard copy and on diskette, preferably usingWordPerfect 5.1, to the editor, NSW Public Health Bulletin,Locked Mail Bag 961, North Sydney 2059. Facsimile (02) 391 9232+
Please contact your local Public Health Unit to obt.ain copies of theNSW Public Health Bulletin.
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